Background
Benign multinodular goiter is one of the most common endocrine surgical problems. The appropriate surgical procedure for its
effective and safe management is a matter of debate. Though seen by some as an overly hazardous procedure because of the risk
of recurrent laryngeal nerve injury and damage to parathyroid function, total thyroidectomy has replaced subtotal thyroidectomy
as the procedure of choice, as the latter is associated with significant recurrences.
Methods
A systemic literature review was undertaken of all available medical literature to evaluate whether total thyroidectomy is
the appropriate, safe and effective surgical procedure for benign multinodular goiter.
Results
There is consistent level II–IV evidence that subtotal thyroidectomy results in recurrence in up to 50% patients. Incidental
thyroid cancers are detected in 3%–16.6% of apparently benign goiters in numerous studies, mostly providing level IV evidence,
one third of which would need further surgical treatment after subtotal thyroidectomy. Studies comparing subtotal thyroidectomy
and total thyroidectomy, including two each of prospective randomized and prospective nonrandomized ones, provide level II–IV
evidence that permanent complication rates associated with subtotal thyroidectomy and total thyroidectomy are not different,
although the rate of transient hypocalcemia is higher with total thyroidectomy. On basis of these findings, a grade B recommendation
can be made that subtotal thyroidectomy is associated with significant recurrence of goiter, leaves a small number of incidentally
detected thyroid cancers inadequately treated, and provides little significant safety advantage over total thyroidectomy.
Grade C recommendations can also be made about total thyroidectomy being a safe and effective procedure for benign multinodular
goiters in the hands of expert surgeons, based on the extensive level IV evidence, and limited level II and level III evidence,
which show that the risk of permanent vocal cord palsy and hypoparathyroidism associated with total thyroidectomy is below
the acceptable 2% rate, but not without exceptions.